All information will be treated with professional confidentiality

    General Information

    Title:

    Surname:*

    Given Name:*

    Preferred Name:

    Date of Birth:*

    Occupation:*


    Address

    Address:*

    Suburb:*

    State:*

    Postcode:*


    Contact Information

    Home Phone:*

    Mobile Phone:

    Work Phone:

    Email Address:*

    Name of private health fund (if any):

    Position on card:


    Emergency Contact Information

    Emergency Contact Name:

    Relationship:

    Phone:


    Dental History

    When was your last thorough
    dental examination?

    How did you come to hear about us?


    What is the reason for your visit today?

    Please write:*


    Medical history

    Who is your Doctor / GP?

    Phone:


    Have you ever had or are you suffering from any of the below?

    Please tick


    Do you have Heart Trouble?:


    Do you smoke?:


    Do you have other symptoms?:

    Are you allergic to anything?:

    What medications including natural
    remedies are you taking?:


    Do you want to discuss any of the following?

    Please tick


    Consent

    Patient or Guardian Name:*


    Date of submission:*


    Signature:*
    (Patient or Guardian to sign if patient is a minor):



    Declaration:*



    * - Required field